Practical considerations in case study research: the relationship between methodology and process

Practical considerations in case studyresearch: the relationship betweenmethodology and process

Ann McDonnell MSc BSc RGN RNT

Lecturer in Nursing, School of Nursing and Midwifery, University of Shef®eld

Myfanwy Lloyd Jones BA MPhil DPhil CHSM

Research Fellow, School of Health and Related Research,

University of Shef®eld

and Susan Read PhD RGN RHV

Senior Lecturer in Research, School of Nursing and Midwifery,

University of Shef®eld, Shef®eld, England

Accepted for publication 9 December 1999

MMcDONNELLDONNELL AA., LLOYDLLOYD JONESJONES MM. && READREAD S. (2000)S. (2000) Journal of Advanced Nursing

32(2), 383±390

Practical considerations in case study research: the relationship between

methodology and process

This paper explores the extent to which the design of a research study is

in¯uenced by pragmatic as well as theoretical considerations by describing the

authors' experience of conducting multiple case studies in the context of a

policy-orientated research project. The case studies in question formed part of a

collaborative project exploring the development of innovative roles in nursing

and the professions allied to medicine. The researchers adopted Yin's approach

to the conduct of multiple case studies to explore issues relating to the

effectiveness of new roles, their resource implications and educational issues

surrounding their development. They address the fact that methodological

decisions have practical implications and also explore the effects of practical

and ethical issues on research design. Three purposively selected acute

National Health Service Trust hospitals in England formed the case study sites

for the work recorded in this paper. In each Trust, three nursing roles were

selected, making nine cases for study. A variety of data collection strategies

were used including semi-structured interviews with post-holders and other

stakeholders (n� 51), non-participant observation of meetings, collection of

audit, ®nancial and statistical data and review of relevant documentation. This

paper describes some of the dilemmas which arose during the course of the

study, the rationale for methodological decisions taken to resolve these

dilemmas and the steps taken to enhance rigour. In particular, the authors

discuss the problems associated with obtaining informed consent in the context

of qualitative research and with member validation of transcripts in a context

Correspondence: Ann McDonnell, ScHARR, University of Shef®eld,

Regent Court, 30 Regent Street, Shef®eld S1 4DA, England. E-mail:

a.mcdonnell@shef®eld.ac.uk

Ó 2000 Blackwell Science Ltd 383

Journal of Advanced Nursing, 2000, 32(2), 383±390 Methodological issues in nursing research

where con®dentiality was crucial. The decision to present ®ndings thematically

rather than as individual cases is justi®ed both in terms of the nature and

purpose of the research and in relation to the particular importance of

anonymity and con®dentiality in this study. Finally, the degree of reciprocity

between researcher and researched is discussed.

Keywords: case study, new roles, ethics, methods, research, evaluation,

qualitative studies, nursing, health care, human resources, workforce

INTRODUCTION

During any research study, investigators have to contend

with the sometimes uneasy relationship between theory

and the practicality of carrying out research in a real-life

setting. The implications of carefully laid plans, made well

in advance, have a habit of `coming out of the woodwork' at

regular intervals during ®eldwork. The authors of this

paper address the fact that, while methodological deci-

sions have very practical implications, the converse also

holds true. The design of any research study is in¯uenced

not just by theoretical but by pragmatic considerations.

This paper explores these issues by describing the

authors' experience of conducting multiple case studies in

the context of a policy-orientated research project with a

®xed time-scale. The paper will aim to describe the

methods used, some of the dilemmas which arose, the

rationale for methodological decisions to resolve these

dilemmas and steps taken to enhance rigour.

BACKGROUND TO THE STUDY

The case studies discussed here were designed to explore a

variety of issues relating to the introduction of new roles in

nursing. They formed part of a wider collaborative research

project, Exploring New Roles in Practice (ENRiP), carried

out by the Universities of Shef®eld and Bristol, and the

King's Fund, a charitable organization devoted to improve-

ments in health care. The ENRiP study was a three-stage

study, carried out in England between February 1996 and

November 1998; it was funded by the Department of Health

under its Human Resources Initiative.

Since 1992, there has been a proliferation of new roles in

nursing and professions allied to medicine (PAMs) in the

United Kingdom's National Health Service (NHS). These

roles have arisen in response to a number of key policy

initiatives which have transformed the NHS. These

include changes in the working hours of junior doctors,

greater discretion for nurses to expand their scope of

practice and new ideas for organizing patient care. All of

this has been in the context of a shift to a system of internal

markets in the NHS from 1990 onwards. Since this time,

individual hospitals or groups of hospitals could apply

for Trust status. This gave them the independence to

determine the service they would provide and the terms

and conditions of service of the staff they employed. NHS

Trust hospitals have therefore been able to respond to the

challenges of providing cost-effective health care in the

1990s with greater freedom and ¯exibility in the way they

con®gure and deploy their workforce. However, the

internal market system is now, in 1999, being superseded

by new commissioning mechanisms designed to encou-

rage partnership rather than competition.

Stage one of the ENRiP project therefore involved a

mapping exercise in England to identify the range and

purpose of new roles which were emerging within acute

NHS Trust hospitals and their outreach centres.

The mapping exercise was conducted in a sample of ®ve

acute Trust hospitals in each of the eight English NHS

regions, selected to allow for wide variation, including large

and small hospitals, urban and rural locations, specialist

and non-specialist hospitals, and teaching and non-

teaching settings (Read 1998). Inquiries were cascaded

down through the organizational structure of each hospital,

resulting in the collection of detailed information on over

800 new roles in nursing and professions allied to medicine.

This information was entered onto the ENRiP database

which was made publicly available in 1997. This database

provided the sampling frame for the selection of cases for

detailed study in stage two.

Finally, in stage three of the ENRiP project a postal

survey of all stage one post-holders was carried out to test

the generalizability of the stage one and stage two ®nd-

ings. The ®ndings of all three stages were used to inform

the production of guidelines relating to the clinical, legal,

professional and educational implications of new role

developments (Levenson & Vaughan 1999).

CHOICE OF CASE STUDY APPROACH

In stage two, three different sets of case studies were

undertaken by each of the collaborating institutions which

formed the ENRiP team. Each team focused on particular

issues which had arisen in stage one, and different meth-

odological approaches were developed by each team in

relation to these issues. The three approaches differed in

some respects. This was in part due to the different

philosophical perspectives held by team members, but also

with respect to practical, ethical and theoretical consider-

ations which were unique to each team. The ability to tailor

A. McDonnell et al.

384 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(2), 383±390

the design of the case studies to accommodate these

differences was seen as a methodological strength. This

paper focuses on the stage two case studies undertaken by

the ENRiP team at Shef®eld University, who adopted Yin's

approach to the conduct of multiple case studies (Yin 1994).

Yin (1994 p. 13) de®nes a case study as:

¼an empirical enquiry that investigates a contemporary phenom-

enon within its real life context, when the boundaries between

phenomenon and context are not clearly evident, and in which

multiple sources of evidence are used.

Yin (1994 p. 1) suggests that case studies are the preferred

research strategy:

¼when `how' or `why' questions are being posed, when the

investigator has little control over events, and when the focus is

on a contemporary phenomenon within some real life context.

On this project, the researchers had no control over the

enormous changes which were taking place at a rapid pace

in NHS trusts and, on the basis of stage one ®ndings, the

University of Shef®eld team were left with a large number of

`How?' and `Why?' questions. A great deal of descriptive

data had been collected in stage one, but the team now

needed to tap into much more detailed and varied sources of

information closer to the individual roles in order to explore

questions which centred around the following themes:

· The effectiveness of new roles: How was this

measured? Why do innovative roles achieve or fail to

achieve their objectives?

· The resources used in setting up and maintaining new

roles: How are these posts funded? Are some posts

under-resourced?

· Educational issues surrounding new role development:

How is education funded? Why are particular educa-

tional programmes seen as valuable or not?

The Shef®eld case studies were intended to be simul-

taneously descriptive, exploratory and explanatory.

Case studies bene®t from prior development of theoret-

ical propositions to guide data collection and analysis

(Yin 1994), and in this study a preliminary conceptual

framework had been developed following stage one and a

list of research questions generated. The use of such a

conceptual framework also allows cross-case comparabil-

ity in ®eldwork involving multiple cases and more than

one researcher (Miles & Huberman 1994). In this study,

®eldwork was to be carried out by two researchers in a

number of settings.

SELECTION OF CASES AND SITES

Rationale for site selection

Three Trusts were selected purposively from those which

had been visited by the Shef®eld team in stage one of the

study. While all three were general hospitals in urban

settings, they varied in size, management strategies and

pay and rewards systems, allowing issues of interest to be

explored across a range of settings. The facility to make

cross-site comparisons in this way was seen as crucial,

since stage one ®ndings had led the Shef®eld team to

propose that variations between Trusts might be an

in¯uential factor in the successful implementation and

sustainability of innovative roles.

Rationale for case selection

In each of the three Trust hospitals, three nursing roles

were selected from those which had been identi®ed in

stage one as innovative Ð these nine roles formed the

cases for study. Several criteria determined the selection

of these cases. In part, they were dictated by practical

issues such as ease of access. However, there were also

crucial theoretical considerations. Cases were selected on

the basis not of representativeness but of illustration.

Sampling criteria therefore included the selection of cases

that would allow cross-case and cross-site comparisons in

relation to the issues in the conceptual framework.

Therefore, roles were included which varied in terms of

their perceived success, their economic implications, the

ways in which èffectiveness' was measured and the post-

holders' educational preparation.

On the basis of information gathered in stage one, the

selected roles included:

· roles which had differences in management support;

· roles where interprofessional con¯icts were evident

and roles where multidisciplinary working was a

notable feature;

· roles where hard outcomes data were available and

roles which did not appear to have been formally

evaluated; and

· substantive posts and posts which had only temporary

funding.

GAINING ACCESS AND ETHICAL APPROVAL

Consent to the Trust's involvement was obtained from the

Director of Nursing Services and/or the Chief Executive.

Two hospitals required local ethics committee approval.

Informal feedback to the research team indicated that the

readiness of some Trusts to participate in stage two was in

part due to the fact that they were satis®ed that the

collection of stage one data in their Trust had been

accomplished with sensitivity and ef®ciency.

INFORMED CONSENT

The dif®culty in obtaining informed consent in qualitative

studies is well documented. Eisner (1991) argues that truly

Methodological issues in nursing research Case study research

Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(2), 383±390 385

informed consent is impossible in such studies because

events in the ®eld cannot be anticipated and researchers

therefore cannot inform participants what to expect.

Similarly, Ford & Reutter (1990) point out the dif®culty

in predicting the exact time commitment involved for

participants in qualitative studies. This had important

implications for the ENRiP study, given that the post-

holders who formed the cases were busy clinicians with

heavy workloads.

Ford & Reutter (1990) also highlight important issues

identi®ed by LaRossa et al. (1981) around the issues of

researching families, which may be analogous to some

aspects of the ENRiP case studies. For example, LaRossa

et al. point out that if participants are interviewed in their

own setting (also the intention of the ENRiP team), the

®eld-worker is treated as a guest as well as a researcher. In

`home' settings, unanticipated events may also occur.

These two factors may lead to a level of disclosure greater

than intended by the participant, thus violating their

autonomy (LaRossa et al. 1981). Ford and Reutter also

contend that participants may ®nd it dif®cult to withdraw

from a study if an authority ®gure (in a family study the

parents, in the ENRiP study a senior manager) consented

to their participation (Ford & Reutter 1990).

All of the above militate against the notion of consent as

a rigid òne-off' request for an individual to enter a study,

but illustrate the need for a more imaginative, ¯exible

approach.

Miles & Huberman (1994) seem to support this stance and

suggest that ongoing dialogue and re-negotiation is needed

for voluntary, informed decisions about the researcher±

researched relationship. Behi (1995) suggests that, in qual-

itative research, best practice is a combination of informed

and process consent, and this was the approach adopted by

the ENRiP team at Shef®eld University.

Preliminary meetings were arranged with potential

case-study post-holders to discuss the ENRiP project

further and seek their co-operation. Post-holders were

assured that their participation was entirely voluntary,

that they were free to refuse to answer any questions or to

be observed, and that they were free to withdraw at any

time. Even where immediate offers to participate were

made, an information sheet was left with post-holders and

their involvement con®rmed by telephone on an agreed

day. Written consent was obtained at the ®rst taped

interview. Consent was then con®rmed and re-negotiated

informally at further meetings, even though some partici-

pants had said at the outset that this would not be

necessary. Some researchers may ®nd elements of this

approach paternalistic. Requests for written information

(®nancial, audit and educational data relating to the post)

were subsequently made by letter.

The post-holders themselves initially identi®ed other

`stakeholders' whom they saw as relevant to their role.

Others informants were in turn suggested by these stake-

holders. All potential informants were approached by the

relevant researcher and consent to their involvement

negotiated.

Only two stakeholders refused to be interviewed Ð one

gave no reason, while the other felt that he was no longer

the most relevant person to interview, and referred the

researcher to his colleague. Overall, the generosity with

which very busy post-holders and stakeholders gave their

time was remarkable. Whether this was in¯uenced by a

positive approach to the ENRiP study at senior manage-

ment level within each trust is a moot point. An awareness

of this placed an onus on both ®eld-workers to avoid any

assumptions regarding access or consent, and to re-con-

®rm willingness to participate at all stages. All site visits

were negotiated in advance with boundaries carefully laid

out and recon®rmed on the day.

DATA COLLECTION METHODS

Case studies typically use both qualitative and quantita-

tive methods of data collection (Yin 1994). Choice among

these methods depends on circumstances within individ-

ual cases, but a clear rationale and some consistency in

approach between researchers is essential to achieve

comparability in analysis (Marshall & Rossman 1989,

Miles & Huberman 1994).

In this study, data collection techniques were developed

using Yin's (1994) approach to developing instrumenta-

tion. Each research question was addressed in terms of

likely sources of data and possible sample strategies,

following which instruments were developed and re®ned,

resulting in the production of a number of consent forms,

information sheets and preliminary interview schedules.

However, as case study methodology implies a research

design which can remain ¯exible throughout the data

collection period, the instruments themselves and the

overall plan for data collection were to some extent

developed during the ®eldwork process.

A variety of data collection strategies were used,

including:

· semi-structured interviews with the post-holders

(audio-taped);

· semi-structured interviews (audio-taped) with stake-

holders, e.g. managers, consultant medical staff, other

colleagues;

· non-participant observation of meetings;

· collection of audit, ®nancial and statistical data;

· review of job descriptions and relevant documents

relating to the post; and

· short questionnaires.

The sequence of events is summarized in Figure 1.

Fieldwork took place over a 10-month period. In all 51

individual interviews were carried out as shown in

Table 1.

A. McDonnell et al.


In addition, one focus group interview was held with

three nurses, and non-participant observation was under-

taken of six meetings.

INCREASING RIGOUR

Triangulation

Using the accounts of different participants draws upon

multiple perspectives Ð this is an important feature of the

case studies and can be seen as a form of triangulation. It

enables the development of a more complete, holistic and

contextual portrayal of real life situations (Jick 1979).

Thus a multidimensional picture of the innovative roles

emerged created by an amalgam of perspectives, rather

than a single view.

Alongside ®eldwork visits comprising interviewing and

observation, a total of 74 documents or sets of related

documents were collected. These included job descrip-

tions, minutes of meetings, course prospectuses, audit

data and patient satisfaction questionnaires.

The use of multiple data collection methods can also be

seen as triangulation (Brink 1991). In this study, it

enhanced rigour by contributing to the search for

`completeness' of data, with each method adding a

different piece to the jigsaw (Kna¯ & Breitmayer 1991).

To a lesser degree, it was viewed as triangulation to

achieve con®rmation/convergence (Kna¯ & Breitmayer

1991). For example, interviewing and observation with

their associated problem of reactivity arising from the

researchers' presence were counterbalanced where

possible, as Denzin suggests, by the use of written and

archival materials (Denzin 1970).

Member validation or not?

A series of interesting discussions arose among the

research team regarding whether interview transcripts

should be fed back to informants for validation. This

might increase the rigour of the study and build into the

case studies some degree of reciprocity Ð which was very

appealing to the research team. However, there were a

number of practical problems associated with member

validation in the context of this study, including organ-

izational dif®culties if informants failed to comment on

time. The content of the stage three survey hinged upon

data emerging from the case studies and thus any delays in

the case studies would impact on the timing of stage three.

The team were also mindful of a number of threats to

validity highlighted by Sandelowski (1993). For example,

participants might be motivated by a wish to justify their

actions, they might wish data to be removed because their

views had changed, or were regretted or forgotten. The act

of reading the transcript for accuracy might cause the

participant to revise his or her views and/or in¯uence the

course of the remainder of the study. More importantly, as

Sandelowski points out, the impact on participants of

seeing what they have said in print has yet to be fully

explored.

In this study, another ethical dimension also existed.

For reasons of con®dentiality, each participant would

only be able to review the transcript of their own

interview, and not those of other relevant stakeholders.

Our case studies involved not just talking to post-

holders, but to their clinical colleagues from their own

and other disciplines, their managers and staff they

managed. It was felt that the opportunity to review a

single interview transcript only (without accompanying

®eld-notes) might give a sense of control over the data

and of the ®nal presentation of the case that was

ultimately misleading. In the context of this study,

member validation might have implied a false sense of

openness that is not defensible.

Figure 1 Summary of data collection process.

Table 1 Summary of interviews carried out

Site D Site E Site F Total

Post-holders 3 3 3 9

Consultants 2 5 4 11

Nurse managers 5 5 1 11

Other managers ± 2 4 6

PAMs 4 3 1 8

SHO ± ± 1 1

Other nurses 3 ± 2 5

Total 17 18 16 51



The team concluded that member validation posed a

serious threat to validity and only offered dubious

bene®ts Ð most notably the `feel good factor' for the

researchers. However, discussions had highlighted other

important ethical issues, including how to effectively

anonymize the data and how to ensure reciprocity.

These issues are addressed in later sections of this

paper.

DATA MANAGEMENT AND ANALYSIS

The team employed a method of analysis which would

address the a priori issues embedded in the research

questions and allow enough ¯exibility to incorporate new

and hitherto unconsidered issues which arose during data

collection.

The `framework' approach

The `framework' approach described by Ritchie & Spencer

(1994) is a systematic approach to the analysis of qual-

itative data around a thematic framework. This framework

is based upon the aims of the study and issues arising

during the research process.

The framework approach involves ®ve stages:

· Familiarization Ð the researcher(s) becomes familiar

with the range and diversity of the material.

· Identi®cation of a thematic framework.

· Indexing Ð the thematic framework is systematically

applied to all the data.

· Charting Ð the data are lifted from their original

context and rearranged according to the appropriate

thematic reference.

· Mapping and interpretation Ð a structure is identi®ed

which illuminates the dynamics of the phenomena

under investigation.

In this study, two researchers were involved in

collecting and analysing data from three different sites,

and the research team had the option of developing a

separate framework for each case or for each site, or of

developing a common index, accommodating additional

elements through extra sub-categories. The team decided

on a common index, in order that common and divergent

themes could be more easily identi®ed. Thus framework 1,

the preliminary framework based on the research ques-

tions, was gradually re®ned to form framework 7

following familiarization by both researchers using a

selection of data from all cases.

NUD.IST

Data analysis was performed using NUD.IST, which was

chosen because of its capacity for dealing with large

volumes of data from a range of sources and its ¯exibility

in coding and recoding (Richards & Richards 1994,

Weitzman & Miles 1995).

The case studies were ®rst analysed individually, using

the multiple sources of data obtained (within-case analy-

sis) to increase validity. Following this, cross-case and

cross-site comparisons were drawn, to test the replicabil-

ity of conclusions (Yin 1994).

Reciprocal coding

Given that analysis was carried out by two researchers, a

number of steps were taken to increase rigour. During the

process of analysis, there was on-going dialogue between

the researchers about the interpretation of the framework

and systematic errors in coding were avoided by means of

this process and by each researcher coding a sample of the

others' documents and comparing results. Cross-case and

cross-site comparisons were also undertaken collabor-

atively.

PRESENTATION OF FINDINGS

Themes or individual cases?

Following the mapping and interpretation stages of

`framework', ®ndings were presented under thematic

headings. Cross-case issues were presented, with infor-

mation from individual cases dispersed throughout each

section. This approach to the presentation of a multiple-

case report is described by Yin (1994). Its adoption was

seen as valid in this study, since the purpose of the report

was not to portray any single case, but to synthesize

lessons from all cases, organized around key topics, in

order to inform the design of the stage three questionnaire.

The fact that a large number of issues which emerged from

these case studies subsequently formed the basis for

survey questions can be seen as some vindication for the

choice of this approach.

However, one justi®able criticism of this approach came

from one of the project's external reviewers who pointed

out that the reader loses any holistic sense of individual

cases. In this study, this was compounded by a decision

not to attribute any quotations to site in order to preserve

anonymity and con®dentiality. The researchers here made

a conscious `trade-off' between making the case studies

`come to life' in the ®nal project report and the preserva-

tion of anonymity. The question of whether this is the

only ethically defensible stance to take or whether we

have somehow devalued the data (and thus the contribu-

tions of all participants) remains.

Anonymity and con®dentiality

The presentation of ®ndings in the manner described was

seen as necessary, because in this study anonymity and

A. McDonnell et al.


con®dentiality were of particular concern, due to a unique

combination of factors which are listed below:

· The existence of the public stage one database, which

included the job titles and contact addresses of all

listed post-holders, made the possibility of tracking a

post-holder back from any case study reports very real.

· The nature of hospitals, which are `small social systems

where everyone knows everyone, [and] even the slight

cues of demographic descriptors¼may reveal a

person's identity' (Archbold 1986 p. 159). This

becomes particularly important when, as in this study,

the participants are few in number and may have high

pro®les within their own setting (Ford & Reutter 1990).

· Negotiation of access with the chief nurse/chief exe-

cutive in each Trust, meant that the identity of the post-

holders was known to them, making the protection of

anonymity on site dif®cult to achieve.

· The case studies involved the researchers talking not just

to the post-holders, but also to their colleagues, managers

and staff they were responsible for. Since there might be

internal con¯icts within any of these relationships, it

was necessary to protect the anonymity of all of these

personnel, sometimes with respect to what they had to

say about each other. This was borne out during ®eld-

work, when some participants would pause to con®rm

that their views were being given in con®dence before

going on to expand on a particular topic. Similar issues

have been highlighted with the publication of studies on

families (Ford & Reutter 1990). In these case studies,

work colleagues may be equated with family members,

and the research team felt a keen obligation to respect the

dynamics of these units.

RECIPROCITY

Given the amount of effort that post-holders, with already

heavy workloads, devoted to the study, the research team

were obliged to consider how reciprocal was the relation-

ship between researcher and researched. In qualitative

research, Miles & Huberman (1994) suggest that informant

bene®ts may include being listened to, gaining insight and

learning and improving personal practice.

Undoubtedly, in this study, many post-holders had the

opportunity to re¯ect on their own practice and to

contribute to the development of policy guidelines

produced following completion of the ENRiP project.

Indeed, one speci®cally stated after the event that ìt was a

pleasure¼to be able to discuss how my role has evolved

and what the future holds, as this also gives me time to sit

back and re¯ect on what has happened within the post'. A

full copy of the ®nal report is also being sent to case study

post-holders with a letter of thanks from the team.

Whether this represents adequate recompense is a ques-

tion for others to address.

SUMMARY

This paper has been a very practical account of some of the

issues and dilemmas presented by conducting a series of

case studies in the context of a piece of policy research

which had three distinct stages. Methodological decisions

regarding the design of these case studies were undoubtedly

in¯uenced by the links between the case studies and other

stages of the ENRiP project.

The strategies adopted to deal with the dilemmas which

arose were developed for a number of reasons. In some

instances, theoretical considerations guided methodologi-

cal decisions. In other instances, practical issues in¯u-

enced research design. Interwoven among these

theoretical and practical considerations there were also

personal and moral issues to be faced.

Yin (1994) contends that case study research is `remark-

ably hard', despite, paradoxically, being traditionally

labelled `soft' research. During this project, the authors

found the case study approach challenging but ultimately

rewarding. The richness of the data obtained through the

adoption of multiple perspectives is without doubt the

strength of this method. The time spent thinking each

issue through carefully at the planning stage, was an

excellent investment which paid dividends throughout

the study. Early consideration was given not only to

methods for collecting and analysing data, but also to how

®ndings would ultimately be presented. However, while

advocating careful planning, the authors also recognize

that this needs to be coupled with the ¯exibility to deal

with the unexpected during the ®eldwork stage, if the

purported bene®ts of this challenging approach are to be

realized in practice.

Acknowledgement

The authors would like to acknowledge the contribution

of the other members of the ENRiP team at Shef®eld

University: Karen Collins (Research Associate) and Roy

Jones (Research Associate). The ENRiP study was

funded by the Department of Health under the Human

Resources Initiative, but the views are those of the

researchers alone.

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Practical considerations in case study research: the relationship between methodology and process